Following the collapse of the Soviet Union twin epidemic of HIV and injection drug abuse enveloped many of the newly emerging countries. Among the countries hardest hit were Russia and Estonia. In both countries, HIV prevalence among injection drug users (IDUs) has expanded rapidly, especially in some cities that lie near the border of the two countries. In St. Petersburg, Russia, HIV prevalence among IDUs has increased from 2% to 43% over the past decade; in Kohtla-Jarve, Estonia, prevalence among IDUs has increased from near zero to nearly 70% this decade. With this increase in infection prevalence, there has grown a pressing need to provide HIV prevention, HIV testing and counseling, HIV medical care, and treatment for the drug addiction that places IDUs at risk for acquiring or transmitting HIV. However, access to these services is compromised by social factors that include ethnic status and stigma directed in up to three ways: towards IDUs, towards those living with HIV infection and AIDS, and towards those of the non-dominant ethnic group. We are proposing a study to ascertain the impacts of ethnicity and stigma on HIV prevalence and on access to care in St. Petersburg and Kohtla-Jarve. We will begin with a rapid policy assessment that allows us to better understand how systems of prevention and care are organized and how IDUs feel about accessing these services. We will follow this with further explorations to understand the nature of the three facets of stigma as perceived by IDUs from the dominant and non-dominant ethnic groups in each city. Lastly, we will conduct a quantitative study to test hypotheses about the impacts of ethnicity and stigma on HIV prevalence and access to prevention and care services. We will test three major hypotheses. The first is that ethnicity is an independent predictor of HIV prevalence, and access to prevention and care; that in St. Petersburg, membership in an ethnic minority will be associated with higher HIV prevalence irrespective of differences in the amount of unsafe injection or unprotected sex while in Kohtla-Jarve, although the majority of the population is of Russian ethnicity, because the politically dominant ethnic group is Estonian, membership in the ethnic Russian majority will be associated with higher HIV prevalence again irrespective of differences in the amount of unsafe injection or unprotected sex. The second hypothesis is that the non-dominant ethnic group in each city will have less access to HIV prevention or medical services. The third hypothesis is that perceived stigma is associated with greater HIV prevalence and with less access to services while, conversely, we will not be able to reject the null hypothesis that ethnic stigma is associated with levels of HIV risk. PUBLIC HEALTH RELEVANCE: The HIV epidemic in Russia and Estonia is driven by viral transmission among injection drug users. This proposal seeks to identify the extent to which ethnicity and stigma influence HIV prevalence among injectors and their access to HIV prevention and care services in St. Petersburg, Russia and Kohtla-Jarve, Estonia.